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Clinical Practice Guidelines

Antithrombotic Therapy
Ischaemic Heart Disease
All patients with suspected acute myocardial infarction or unstable angina not already taking aspirin
should be given aspirin (150-300 mg) as soon as possible (unless contraindicated)
General practitioners should carry aspirin so that treatment can be initiated at diagnosis
Patients with acute myocardial infarction should also be considered for thrombolysis as quickly as
possible after the onset of symptoms
Patients who are hospitalised with severe unstable angina should also be considered for full dose
heparin or low molecular weight heparin
All patients with previous myocardial infarction, angina, or previous coronary artery surgery or
angioplasty should (unless contraindicated) be considered for antiplatelet prophylaxis, usually with
aspirin (75-300 mg/day)
In patients with contraindications to aspirin, clopidogrel (75 mg/day) should be considered for
prophylaxis

Cerebrovascular Disease
Patients with acute stroke should have an early CT scan (preferably within 48 hours and no later
than seven days)
Patients shown to have ischaemic stroke should receive aspirin as soon as the diagnosis is confirmed
(150-300 mg) (unless contraindicated)
Anticoagulant therapy should be reserved for acute ischaemic stroke patients with a high risk of
either venous thromboembolism or recurrent thromboembolic stroke
Patients with TIA should be investigated promptly
Patients with ischaemic stroke or TIA should (unless contraindicated) receive secondary
prevention with one of:
• aspirin (75-300 mg/day)
• dipyridamole (200 mg twice daily) for patients intolerant of aspirin and (in combination with aspirin)
for those with recurrent events despite aspirin
• clopidogrel (75 mg/day) for patients intolerant of aspirin
• warfarin in suitable patients with atrial fibrillation or other suspected cause of cardioembolic
stroke
Following carotid endarterectomy, patients should (unless contraindicated) receive aspirin
(75-300 mg/day)

Peripheral arterial disease
Patients with intermittent claudication or a history of peripheral angioplasty or arterial grafts should
receive aspirin (unless contraindicated) or clopidogrel (75 mg/day)

diabetes mellitus.Atrial Fibrillation (For other cardiac causes of systemic embolism.5. see full guideline.0) reduces stroke risk by 68% Aspirin (75-300 mg/day) reduces stroke risk by 20% Patients with AF but without additional risk factors require no antithrombotic prophylaxis unless there are other indications for aspirin. or non-cerebral thromboembolism The decision to use warfarin or not should be based on discussion of the balance of risk and benefit with each individual. compliance assessed and the risks and benefits of warfarin reviewed annually. no other risk factors .previous ischaemic stroke or TIA High: . For recommended anticoagulant cover for cardioversion. especially in those aged over 75 years Cardioversion to restore sinus rhythm should be considered in selected patients.0-3. thyrotoxicosis. Or Warfarin In High. including assessment of compliance To minimise the risk of intracranial bleeding in patients on warfarin.age over 65 and one other risk factor (hypertension.age over 65. heart failure. hypertension should be controlled. other risk factors Low: .age under 65. see full guideline) Risk factors for systemic thromboembolism should be assessed routinely in all patients with atrial fibrillation Risk factors for thromboembolism in AF are: • • • • • • previous ischaemic stroke or TIA age over 65 years hypertension diabetes mellitus cardiac failure echocardiography showing LV dysfunction or mitral valve calcification Warfarin (target INR 2. Moderate And Low Risk Patients With Non-valvular Atrial Fibrillation Risk group Very high: .age under 65. Patients with one or more risk factors should be considered for warfarin therapy in preference to aspirin Warfarin prophylaxis should also be considered in patients with atrial fibrillation and heart valve disease or prostheses. because it may avoid the need for long term warfarin. range 2. LV dysfunction) Moderate: . no other risk factors * Number needed to treat with warfarin instead of aspirin for one year to prevent one stroke . intracardiac thrombus. Aspirin. Annual Risk Of Stroke On No Treatment.

or . either: .serial (repeat after seven days) non-invasive testing by ultrasound to detect proximal extension of calf DVT A single negative ultrasound may be sufficient to exclude DVT in patients with low clinical pre-test probability and/or a normal fibrin D-dimer assay HEPARIN IN ACUTE TREATMENT OF DVT OR PE Outpatients with clinically suspected DVT or PE should be referred to hospital for diagnosis and consideration of initial anticoagulation with heparin A In clinically-suspected DVT or PE.g.0-3.0 The routine recommended duration of oral anticoagulant therapy following a first episode of DVT or PE is at least three . ultrasound) or PE (e.5. ventilation-perfusion lung scanning) to minimise exposure to the risks of inappropriate continued full-dose anticoagulation in those patients in whom venous thromboembolism is not confirmed In all patients with clinically-suspected DVT. Low molecular weight heparins are effective alternative treatment to unfractionated heparin for DVT or PE ORAL ANTICOAGULANTS IN ACUTE AND MAINTENANCE TREATMENT OF DVT OR PE If therapeutic anticoagulation is contraindicated.contrast venography (detects both calf and proximal DVT). range 2. the diagnosis should be confirmed or excluded by diagnostic imaging. or .Venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) DIAGNOSIS OF ACUTE VENOUS THROMBOEMBOLISM Diagnostic imaging should be performed expeditiously (within 24 hours if possible) in patients with suspected DVT (venography. maintenance of anticoagulation with oral anticoagulants is recommended in non-pregnant patients. and heparin doses adjusted according to a local protocol to achieve the therapeutic target range (usually 1.non-invasive testing by ultrasound (compression or Duplex scanning) followed by contrast venography if negative to detect calf DVT and non-occlusive proximal DVT. heparin should be commenced (unless strongly contraindicated) until the diagnosis is excluded by objective testing Monitoring of the APTT ratio should be performed expeditiously in patients receiving unfractionated heparin.5-2. inferior vena cava (IVC) filter insertion should be considered Following initial heparinisation in patients with DVT or PE. the advisability of any continued anticoagulant therapy following hospital discharge should be assessed critically Early institution of oral anticoagulants is recommended in most patients A The optimal target INR during oral anticoagulant therapy for a first episode of venous thromboembolism is 2.5) within 24 hours Subcutaneous unfractionated heparin is an effective alternative to intravenous unfractionated heparin for the initial treatment of DVT. Adjusted-dose subcutaneous heparin may be considered as an alternative therapy In intravenous drug users.

thrombophilias. or until risk ractors resolve Patients with thrombophilias should be referred to consultant haematologists or to centres with expertise in management of these patients OTHER ANTITHROMBOTIC THERAPIES IN TREATMENT OF DVT OR PE Graduated elastic compression stockings should be worn on the affected leg following proximal DVT for at least two years to reduce the incidence of severe post-thrombotic leg syndrome . chronic infection. nephrotic syndrome. inflammatory bowel disease.At three months. malignancy.g. thromboembolic pulmonary hypertension) The presence of continuing risk factors suggests consideration of anticoagulation long term. patients should be assessed for continuing risk factors (e. idiopathic. premature or familial presentation.

and communicating results to patients accurately Surgeons. or dose reduction. vitamin K1 (0. Any such patients who have head injury.5-2 mg IV or 5-10 mg orally) In patients with life threatening haemorrhage: . severe).0. but more frequently when change in clinical state or medication Patients and/or relatives or carers should be educated on advice in the DoH oral anticoagulant booklet Clinicians providing anticoagulant care must have explicit systems for handling results promptly.in addition. to achieve a lower INR .substitution of heparin The most common cause of fatal or disabling bleeding in patients receiving anticoagulant therapy is intracranial or intraspinal bleeding. headache (recent.factor IX complex concentrate should be given at a dose of 50 IU/kg body weight: such therapy is more efficacious than fresh frozen plasma . followed by appropriate reversal of anticoagulant therapy .Dosage. Monitoring. confusion.if factor VII concentrate is available it should be given at a similar dose . repeated as necessary) Possible means to reduce the risk of excessive bleeding during and after surgery or other invasive procedures include: . And Contraindications To Antithrombotic Drugs WARFARIN Dose: usually 1-15 mg/day to maintain target INR (range usually 2.0) or other risk factors for bleeding.elective discontinuation of oral anticoagulant. patients with certain mechanical heart valves or recurrent thromboembolic events require higher target ranges) Monitoring of INR should be performed at 4-8 week intervals when stable. impaired consciousness. warfarin should be stopped for 1-2 days and vitamin K1 given (0.5 mg IV or 5 mg orally) should be considered In patients with non-severe bleeding and a high INR. Reversal. dentists and physicians intending to perform surgery or invasive procedures in patients receiving anticoagulant therapy should seek advice concerning management of such therapy from a haematologist In patients with a high INR (>8. intravenous vitamin K1 should be given (5 mg.urgent reversal of oral anticoagulant therapy . or focal neurological symptoms and signs should have urgent CT scanning to detect such bleeding.0-3. making informed decisions on further treatment and testing.

e. stop heparin if thombocytopenia detected CONTRAINDICATIONS TO AND CAUTIONS WITH FULL-DOSE ANTICOAGULANT DRUGS (Note: these depend on individual circumstances and are seldom absolute) • Uncorrected major bleeding • Uncorrected major bleeding disorder . oesophageal varices aneurysm.ASPIRIN Dose: 75-300 mg/day is as effective as higher doses Although 75 mg/day suppresses platelet aggregation in most patients after several days.e. except in certain patients with prosthetic heart valves or recurrent thromboembolism with one or other drug alone FULL DOSE UNFRACTIONATED HEPARIN Monitor APTT ratio to achieve target range (usually 1. or co-prescribing antacids. haemophilias.5-2. misoprostol. systolic >200 mm Hg or diastolic >120 mm Hg • Potential bleeding lesions . thrombocytopenia.5) Monitor platelet count after five days therapy. liver failure. proliferative retinopathy recent organ biopsy recent trauma or surgery to head. spine recent stroke confirmed intracranial or intraspinal bleed • Heparin history of heparin-induced thrombocytopenia or thrombosis • Warfarin pregnancy (usually) homozygous protein C deficiency (risk of skin necrosis) history of warfarin-related skin necrosis uncooperative/unreliable patients (long term therapy) . active peptic ulcer. using dispersible or enteric-coated preparations. orbit.e.g. renal failure • Uncontrolled severe hypertension .g.g. proton pump inhibitors or H2-receptor antagonists Concomitant use of warfarin should be avoided. earlier effects are achieved with 150-300 mg in acute myocardial infarction or acute ischaemic stroke The risk of major GI bleeding is 1:500 patient-years and is dose dependent above 300 mg/day Gastric intolerance can be reduced by using the minimum effective dose (75 mg).